Intensive Management of At-risk Patients

CareMore Health, San Bernardino600 enrolled

Overview

The purpose of this study is to assess if intensive management of at-risk participants, utilizing longitudinal patient tracking, proactive outreach, multidisciplinary action planning and careful outcomes monitoring, will lead to better patient outcomes than usual care.

At-risk participants will be randomized 1:1 to either usual care or intensive management utilizing longitudinal patient tracking, proactive outreach, multidisciplinary action planning and careful outcomes monitoring for 6 months. Participants in the intervention group will be assigned to a partnership of one nurse practitioner and one medical assistant who will manage them with the support of the study team. Staff will focus on contacting all patients within one week of any emergency department visit or hospital discharge, contacting all highest-risk participants weekly and all participants monthly, and completing high-priority tasks for participant care within one week. The primary outcomes of this quality improvement study are inpatient bed days and number of inpatient admissions.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

SINGLE

Enrollment

600

Conditions

Chronic Disease

Interventions

Intensive managementBEHAVIORAL

The intervention group will be assigned to a partnership of one nurse practitioner and one medical assistant who will manage them intensively, with the support of the study team.

ControlBEHAVIORAL

Usual care

Eligibility

Sex: ALLHealthy volunteers:

Medical Language ↔ Plain English

Inclusion Criteria: At-risk patients, meaning Gold, Silver, or Bronze tier, as identified by our member 360 platform: * Gold tier - 6+ emergency department (ED) visits last year, annual spend \>$100,000, 8 or more hierarchical condition category (HCC) diagnoses, readmission \<30 days prior, or ambulatory care-sensitive condition (ACSC) hospitalization \<30 days prior * Silver tier - 4+ ED visits last year, annual spend \>$75,000, 6 or more HCC diagnoses, readmission \<90 days prior, substance abuse HCC diagnosis, behavioral health admit \<90 days, 15+ chronic medications prescribed in the last 90 days (and not qualifying for Gold tier) * Bronze tier - 3+ ED visits last year, annual spend \>$50,000, 5 or more HCC diagnoses, 3+ hospitalizations last year, end-stage liver disease, end-stage renal disease, Medicare and Medicaid dual-enrolled, disease-management program patients with ACSC admission or ED visit in the last year, 10+ chronic medications in the last 90 days, 6+ health risk-assessment score, 12+ Edmonton Frail Scale score (and not qualifying for Gold or Silver tiers) Exclusion Criteria: * enrolled in hospice * enrolled in Institutional Special Needs Plan * primary patient of study investigator

Outcomes

Primary Outcomes

inpatient bed days

number of total participants' days of care in an inpatient setting

Time frame: 6 months

inpatient admissions

total number of participants' inpatient admissions

Time frame: 6 months

Secondary Outcomes

ED visits

participants' total emergency department visits

Time frame: 6 months

30-day readmissions

participants' total inpatient readmissions within 30 days

Time frame: 30 days

180-day readmissions

participants' total inpatient readmissions within 180 days

Time frame: 180 days

ACSC admits

participants' inpatient admissions for ambulatory care sensitive conditions

Time frame: 6 months

inpatient plus SNF bed days

number of total days of participants' care in an inpatient or skilled nursing facility setting

Time frame: 6 months

cost

participants' total medical expenditures

Time frame: 6 months

delta MLR

average change in each participant's medical loss ratio

Time frame: 6 months

Central Contacts

Paul J Bixenstine, MD

CONTACT

909-296-8800 paul.bixenstine@caremore.com

Data from ClinicalTrials.gov

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